Indiana Department of Environmental Management



Noncompliance 24-HOUR Notification Report

State Form 52415 (R / 10-13)

Indiana Department of Environmental Management

Office of Water Quality

INSTRUCTIONS: Complete all sections of this form and email it to Office of Water Quality, Compliance Data Section at wwreports@idem.. Thorough completion of this report will satisfy the Office of Water Quality (OWQ) telephone and 5-day written noncompliance notification reporting requirements of your NPDES permit. To speak with someone in OWQ, call (317) 232-8670.

Additionally, any noncompliance which may pose a significant danger to human health or the environment (including a fish kill) must be immediately reported to the Emergency Response Section spill response line at: (317) 233-7745 or toll free within Indiana at (888) 233-7745.

|FACILITY INFORMATION |

|Facility Name |County |NPDES Permit Number |

|      |      |      |

|Individual Reporting |Telephone Number |Reporting Date (month, day, year) |

|      |      |      |

|Email Address |

|      |

|NONCOMPLIANCE INFORMATION |

|Date (month, day, year) |Outfall |Parameter |Permit Limit (Units/Daily/Weekly/Ave/Max/Min) |Monitored Value |

|      |      |      |      |      |

|Date (month, day, year) |Outfall |Parameter |Permit Limit (Units/Daily/Weekly/Ave/Max/Min) |Monitored Value |

|      |      |      |      |      |

|Description of the Noncompliance and its Cause: |

|      |

|Description of the Period of Noncompliance, Including Exact Dates and Time, and if the Noncompliance has not been Corrected, the Anticipated Time it is Expected|

|to Continue: |

|      |

|Steps Taken or Planned to Reduce, Eliminate, and Prevent Reoccurrence of the Noncompliance: |

|      |

|CERTIFICATION AND SIGNATURE |

|I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to |

|assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or |

|those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and |

|complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing |

|violations. |

| |

|SIGNATURE:      _________________________________________________________ DATE (month, day, year):      ________ |

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